1. Intravenous Antibiotics in the Community
Lilian Li
Principal Microbiology Pharmacist
Imperial College Healthcare NHS Trust
St Mary’s Hospital
Thanks to Jan Hitchcock, Dr Hand & Dr Conlon

2. Aim & Objectives
To improve knowledge on intravenous (IV) antibiotics used in the community
Become familiar with some of the infections treated
Become familiar with some of the pathogenic micro-organisms involved
List the ideal properties of a suitable antibiotic for use in the community
List the most common antibiotics used
State how to administer those antibiotics
Be familiar the side-effects associated with these antibiotics to be monitored
List sources of support

3. Lactose-fermenting coliforms E coli, Klebsiella, Enterobacter
Gram +ve Cocci (spherical) Staphylococci Streptococci Enterococci Peptococci/Peptostreptococci*
Gram -ve Cocci Neisseria meningitidis Neisseria gonorrhoea Moraxella catarrhalis Acinetobacter (coccobacillus)
Gram +ve Rods Clostridia* Corynebacteria (diphtheroids) Listeria Bacillus *Anaerobes
Gram -ve Rods
Bacteroides*
Lactose-fermenting coliforms
E coli, Klebsiella, Enterobacter
Non lactose-fermenting coliforms
Proteus, Salmonella, Shigella
Pseudomonas
Haemophilus
Helicobacter, Campylobacter
Legionella
Start off with basic understanding of classification of bacteria as will use these terms later

4. Generally... Gram -ve GI-tract Anaerobes
Mouth, teeth, throat, sinuses & lower bowel
Gram +ve
Skin & mucous membranes
Atypicals
Chest and genito-urinary
Cert

5. The perfect IV antibiotic for use in the community
Efficacy, safety, cost
Ease of administration
bolus vs. infusion
Pharmacokinetics
long half-life allows once or twice daily dosing
Stability
dry or diluted
room temperature or refrigerated
Compatibility
with other antibiotics
with saline and heparin flushes

7. Pattern of Activity
Antibiotics
Goal of Therapy
PK/PD Parameter
Type I Concentration-dependent killing & Prolonged persistent effects
Aminoglycosides Daptomycin Fluoroquinolones Ketolides
Maximize concentrations
24h-AUC/MIC Peak/MIC
Type II Time-dependent killing and Minimal persistent effects
Carbapenems Cephalosporins Erythromycin Linezolid Penicillins
Maximize duration of exposure
T>MIC
Type III Time-dependent killing and Moderate to prolonged persistent effects.
Azithromycin Clindamycin Oxazolidinones Tetracyclines Vancomycin
Maximize amount of drug
24h-AUC/MIC

8. Extract from Table 5. Tice AD et al. CID 2004, 38:1651-72

9. Which antibiotics? Ceftriaxone Teicoplanin Ertapenem Ceftazidime
Meropenem
Gentamicin

10. Ceftriaxone 3rd generations cephalosporin
Activity: Gram negative and positive bacteria
5-10% cross sensitivity to penicillins
Side-effects
GI upset, diarrhoea, n&v (precipitation in gall bladder)
Administration
Bolus
reconstitute 1g with 10ml WFI & infuse over 3-5 minutes
Intermittent infusion
Reconstitute 2g with 40ml N/Saline & infuse over 30 minutes

11. Teicoplanin Glycopeptide
Activity: Serious Gram positive infection resistant to other antibiotics
Contra-indicated if patient vancomycin allergic
Side-effects
Rash, n&v, hearing impairment, renal impairment
Administration
Bolus
Reconstitute vial with 3ml WFI, roll & rest. Infuse over 3-5 minutes

12. Ertapenem
Carbapenem
Activity: broad spectrum (Gram +ve/-ve and anaerobes)
CARE! Sodium valproate / valproic acid
Contra-indication
Anaphylaxis to β-lactams
Side-effects
Rash, n&v,  LFTs,  platelets
Administration
Reconstitute 1g with 10ml WFI, dilute up to 50ml with N/Saline. Infuse over 30 minutes.

13. Ceftazidime 3rd generations cephalosporin
Activity: Gram -ve and +ve bacteria
5-10% cross sensitivity to penicillins
Side-effects
GI upset, diarrhoea, n&v
Administration
Bolus
reconstitute with 10ml WFI or N/Saline & infuse over 3-5 minutes

14. Meropenem
Carbapenem
Activity: broad spectrum (Gram +ve/-ve and anaerobes)
Contra-indication
Anaphylaxis to β-lactams
Side-effects
GI upset, injection site reactions, headache
Administration
500mg vial with 10ml WFI, infuse over 5 minutes.

15. Gentamicin Aminoglycoside Activity: Gram -ve Side-effects
Ototoxicity, nephrotoxicity
Administration
Dilute 1g with 10ml N/Saline, infuse over 3-5 minutes.
TDM
Pre-dose = trough
Aim < l mg/L

16. If one dose is given… peak Serum concentration trough time Dose
Tds dosing
If sample taken an hour post dose
t = 8-1 = 7 hours
trough
time
Dose

17. What we want… Serum concentration trough time Dose Dose Dose Dose Dose
Tds dosing
If sample taken an hour post dose
t = 8-1 = 7 hours
time
Dose
Dose
Dose
Dose
Dose

18. If doses too close together
Serum concentration
trough
Tds dosing
If sample taken an hour post dose
t = 8-1 = 7 hours
time
Dose
Dose
Dose
Dose
Dose
Dose

19. How often should gentamicin be given

20. Infusion Devices Human with syringe and needle Gravity drip IVAC pump
Syringe driver
Elastomeric device (e.g. Intemate)
CADD (programmable portable device)

21. OPAT complications Drug-associated Line-associated Other GI upset Rash
Fever
Neutropenia
Anaphylaxis
Renal
Line-associated
Infection
Leakage
Phlebitis
Thrombosis
Other
Rx related
Unrelated

23. OPAT team BNF Microbiology Pharmacists Medicines information
Drug monographs
Community chemist
CNS Nurses
Anu Viljanen
Jan Hitchcock
Microbiology Pharmacists
Tracy Lyons
Lilian Li
Medicines information

24. Summary Safe and effective Saves thousands of bed days
Highly dependent on liaison nurses
Number of nurses are rate-limiting
High patient satisfaction
A model for NHS hospital / community cooperation